# Digital Health and Fiscal Credibility in Low‐ and Middle‐Income Countries: A Scoping Review of Practice‐Based Evidence

## TL;DR

This study reviews how digital health can improve fiscal credibility in low- and middle-income countries by reducing costs and improving financial transparency.

## Contribution

The paper provides practice-based evidence on how digital health initiatives can strengthen fiscal credibility and be made investable under fiscal rules.

## Key findings

- Digital platforms reduce leakage and generate efficiency gains in LMICs.
- Integration with budgeting improves predictability and trust, enhancing fiscal credibility.
- Investability improves with proper governance and performance-based budgeting.

## Abstract

Digital health is widely promoted in low‐ and middle‐income countries (LMICs), yet investment is often constrained by fiscal rules and borrowing limits. Policymakers also struggle to explain how digital health improves fiscal sustainability and, by proxy, fiscal credibility, creating a gap between technical promise and investable policy narratives.

To synthesise practice‐based evidence on whether and how digital health initiatives in LMICs contribute to fiscal sustainability and signal fiscal credibility to governments, funders, investors, and to identify design and governance conditions that make these benefits investable under fiscal‐rule frameworks.

A scoping review following PRISMA‐ScR analysed 45 studies (2010–2025) of LMIC digital health interventions that reported economic outcomes (e.g., cost‐effectiveness, cost savings, ROI, budget impact) and/or credibility proxies (e.g., integration with public financial management, budget absorption, stakeholder trust). Findings were synthesised thematically.

Evidence shows that digital platforms curb leakage and generate efficiency gains (e.g., reduced wastage, streamlined claims) and avert future costs through prevention and adherence, while integration with budgeting and public financial management improves predictability, transparency, and trust, thereby strengthening credibility signals. Yet benefits are frequently non‐cashable without managerial and policy reforms; costs and savings are misaligned across actors; and classifying digital outlays as recurrent restricts access to capital envelopes despite favourable economics. Investability improves when core platforms are treated as public digital infrastructure with clear depreciation and financing arrangements, when efficiency gains are translated into real budget space via gain‐sharing and performance‐based budgeting, and when reporting explicitly links digital performance to fiscal outcomes. These effects depend on foundational enablers, including infrastructure, workforce capacity, and sustained user engagement.

When embedded in robust governance and public financial management, and framed as rule‐consistent investment, digital health can expand fiscal space, support compliance with fiscal rules, and strengthen fiscal credibility, helping LMICs reassure lenders and justify sustainable borrowing for health system strengthening.